Job Application

Applicant Information

Tell us about yourself


Please check all that apply.

AmbulationBath/Shower/SpongeBedboundCar TransportationColostomyCompanionshipDementiaDementia ExperienceDress/GroomFall RiskFeedFeeding TubeGaitHospice CareHospice ExperienceHoyerIncontinence CareLight ExerciseLight HousekeepingLive-In Shifts OKMeal PreparationMed RemindersMonitor and WanderingNo DrivingOK with Client SmokingOut of Home ActivitiesSlide BoardToiletingWears BriefsTransfers: Gait Belt ExperienceTransfers: Hoyer Lift ExperienceOK with CatsOK with Dogs

Education & Training

High SchoolCollege (please specify)

Certification & Credentials

Please check all that apply.

CNA LicenseCPR CertificationDriver's LicenseFirst Aid CertificationHHA CertificationLVN/LPN CertificationRegistered NurseTuberculosis Test

Employment History

Please provide your most recent positions of employment.

Dates Employed:

Dates Employed:

Dates Employed:

Professional References

Additional Information

Are you 18 years of age or older?
Are you legally eligible for employment in the United States?
May we contact your current employer to verify your employment history?
Do you have text messaging capabilities on your cell phone?

How did you hear about Immaculate Home Care Services?

Have you ever worked under a different name? If yes, please specify

Have you ever been convicted of, or plead guilty to, a felony or misdemeanor? If so, please explain the date and nature of the offense.

Do you have at least one year of experience working (paid or unpaid)? Please describe this experience

Describe your training and/or experience with seniors or disabled individuals.

Are you willing to provide personal care to seniors or disabled individuals?

Please list your availability to work. Be specific as to days and hours.

Are there any specific times you are UNAVAILABLE to work?

We require our caregivers are required to work at least one shift every other weekend. Are you willing to work every other weekend?What is your specific availability to work on the weekends?

Emergency Contact: (Name and Phone Number)


I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and / or discharge at any time during employment. I authorize Immaculate Homecare Services to verify any and all information contained within this application including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this and information. I also understand that the use of illegal drugs is prohibited during employment that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment. RESTRICTIVE COVENANT: I agree not to do business directly with any individual or business entity that Immaculate Homecare Services has introduced me to or by entering into employment with such individuals or businesses. I have checked the above and each section of the application has been completed. (An incomplete application will be rejected.) Do you certify and agree to the above stated?

Yes, I certify and agree to the above stated